March 31, 2014

In a first of its kind retrospective study, Boston University School of Medicine (BUSM) researchers have found that providing health insurance coverage to previously uninsured people does not result in reducing 30-day readmission rates. The study, which appears in the British Medical Journal, used data on actual (versus self-reported) use of care and also found no change in racial/ethnic disparities in this outcome, despite a markedly higher baseline of uninsurance among African-American and Hispanics in Massachusetts.

Readmissions have been the focus of health policy interventions to reduce costs with particular focus given to uninsured and minority populations who are at increased risk for frequent readmissions. In March 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The law established a Hospital Readmissions Reduction Program, which requires the United States Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.

Prior studies suggest that when individuals have insurance, they are more likely to have a usual source of care and to utilize medical care, which can prevent unnecessary and costly hospitalizations. However, it is unknown whether expanding health insurance coverage can reduce the risk of readmissions in the overall population, specifically among minority populations.

In order to determine whether readmission rates changed in Massachusetts (which implemented health care reform in 2006) relative to two control states, (New York and New Jersey), which did not enact coverage expansions during the study period, the researchers compared all-payer inpatient discharge databases. Following health reform implementation, Massachusetts individuals experienced a very slight increased risk of 30-day readmissions, relative to similar age individuals in New York and New Jersey.

The researchers also examined whether disparities in readmission rates changed subsequent to reform, hypothesizing that minorities in Massachusetts might stand to benefit the most, as they are at increased risk for readmissions and made the most gains in terms of insurance coverage.

"Among African-Americans and Hispanics, we found the odds of readmission did not decrease in Massachusetts relative to control states, and there was no change in the magnitude of the white-black and white-Hispanic difference in readmission rates," explained lead author Karen Lasser, MD, MPH, an associate professor of medicine at BUSM.

According to the researchers there are several possible explanations for their findings. For example, following health reform in Massachusetts, newly insured individuals were more able to seek medical attention after a hospital admission, which in turn may have uncovered medical problems requiring readmission. Another reason may be the inability to access a personal doctor in the state due to the primary care physician shortage, which has been well documented since 2006.

Other studies in Massachusetts have shown that access to care improved less than access to insurance, as many newly insured residents who obtained Medicaid or state subsidized private insurance still reported cost-related access barriers. "In addition to persistent financial barriers to accessing care (high co-pays, premiums, deductibles and uncovered services) for those with insurance gained under the reform, many providers do not accept these public forms of insurance because of low reimbursement rates," added Lasser.

The researchers believe that in order to reduce readmissions and disparities in readmissions, states in the U.S. like Massachusetts need to go beyond simply expanding insurance coverage.

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